Irina Volynsky, Ph.D.
Clinical Director
NYS Lic. 68-017595 NJS Lic. 4732
440 West Street, Fort Lee, NJ 07024
(347) 879-0202
PSYCHOLOGIST-PATIENT SERVICE AGREEMENT
NOTICE OF PRIVACY PRACTICES
(Page 1of 7 Pages)
This notice contains important information about my professional services and business policies; it also will tell you about how I, Irina Volynsky, handle information about you and your child (further both of these entities are referred as "patient" or "you"). In addition, it contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protection and explains patient rights with regard to the use of disclosure of your Protected Health Information (PHI), used for the purpose of evaluation, treatment, payment, and health care operations.The law protects the privacy of all communications between a patient and a psychologist. In most situations I can only release information about your evaluation or treatment to others if you sign a written authorization form that meets certain legal requirements imposed by state law or HIPAA. Patients who are 14 or older must sign the written authorization form. The law requires that I obtain your signature acknowledging that I have provided you with this information. When you sign this document, it will represent an Agreement between us. You may revoke this Agreement at any time. That revocation will be binding on me unless there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy, or if you have not satisfied any financial obligations you have incurred.
PSYCHOLOGICAL SERVICES
Various psychological services include evaluation and testing, consultation, and psychotherapy. Evaluation and testing is usually conducted at your request or request of other professionals or agencies. It may include gathering of developmental history, the testing itself, in-vivo observation if applicable, feedback session, and presenting you with a written report.Consultation usually includes discussing your presenting problem and treatment options that are available; referrals will also be presented to you. Psychotherapy varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods I may use to deal with problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness or helplessness. On the other hand, psychotherapy has also been shown to benefit people who go through it. Therapy often leads to betterrelationships, solutions to specific problems, and significant reductions in feelings of distress. However, one cannot predict how these experiences will unfold, or how intense these experiences will be for you.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, impressions of what our work will include will be discussed if you decide to continue with me. You should consider this feedback carefully, along with your impressions of how we would work together and whether you feel comfortable going forward. Like any relationship, therapy involves a large commitment of time and energy, as well as a financial commitment, so you should be very careful about the therapist you select. Please feel free to ask any questions you have about my approach so that we may discuss them whenever they arise. If your doubts persist, I will be happy tohelp set you up with a consultation with another mental health professional for a second opinion.
PROFESSIONAL FEES
My fee is $____ per 50-minute individual session and $_____ for 60-minute evaluation, couples or family session. In cases in which my fee would pose a clear financial burden, I may negotiate a fee reduction at my discretion. In addition to weekly appointments, I charge this amount for other professional services, such as consultations, report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other services you may need. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. My fee is subject to change at any time and you will be notified thirty (30) days in advance of this change.CONTACTING ME
I am not immediately available by telephone and I do not answer the phone when I am in session. When I am unavailable, my telephone is answered by voice mail and I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of times that will be available and I will try to call you back then. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or go to the nearest emergency room. If I am unavailable for an extended period of time, I will provide you, in advance of my absence, with the name of a colleague to contact, in the event of an emergency.At our request, limited communication may occur via email or text messages, such as you informing me of appointment cancellation or a need to reschedule. At your request, I may respond to such an email or text. You should be aware that such communication is not secure and confidential by its nature, and you should not provide me with any information via text or emails that you are not comfortable disclosing to general public.
BILLING AND PAYMENTS
I expect full payment at the end of every session. If you need to miss a session and inform me at least 24 hours in advance, I will offer you a make-up appointment within the next 2 months. However, if you missed a session without 24-hour notice, I have a right to charge you the full amount for this session. Please note that insurance companies typically do not provide reimbursement for cancelled or missed sessions. I will inform you in advance of my vacation and will expect you to discuss such plans as well. At the end of each month you will be presented with a written statement of services provided, which includes dates of your sessions and amount paid. You should keep track of your sessions, as errors are always possible. Please bring any discrepancies to my attention for review.If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment. This may involve hiring a collection agency or filing an action in small claims court. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.
INSURANCE REIMBURSEMENT
I practice mostly on a self-pay basis. If you have a health insurance policy, it may provide some coverage for out-of-network mental health treatment. I will provide whatever assistance I can to help you receive benefits to which you are entitled. However, in the end, you - not your insurance company - are responsible for full payment.PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. It is likely to include the following:• Your personal history
• Reasons you came for treatment: problems, symptoms, needs, goals
• Diagnoses: medical terms for your problems, symptoms, disabilities
• Treatment Plan: services that I think will help you
• Progress Notes
• Records from others who treated or evaluated you
• Psychological test scores, school records, and the like
• Information about medications you are taking
• Legal matters
• Billing and insurance information
Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record (electronic or paper, depending on the way information was stored), if you request it in writing. Because these are professional records, they can be misinterpreted to untrained readers. For this reason, I recommend that you review them in my presence so that we can discuss the contents. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
PATIENTS RIGHTS
HIPAA provides you with expanded rights with regard to your Clinical Records and disclosures of Protected Health Information (PHI). These rights include requesting that I amend your record, requesting restrictions on what information from your Clinical Record is supplied to others, requesting an accounting of most disclosures of Protected Health Information that you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, having any complaints you make about my policies and procedures recorded in your records, and the right to a paper copy or electronic copy of this Agreement, the included Notice Form, and my privacy policies and procedures.In addition, you have the right to equal consideration and treatment regardless of your sex, age, race, religion, color, economic status, or sexual preference. You have the right to know my assessment of your (or your child’s) problem, the recommended treatment plan, and resources available to help improve this problem. You also have the
right to refuse treatment, which means that even though I may strongly suggest that you (and/or your child) seek help, you may choose to not follow my advice. Should you choose to refuse treatment, you will be advised of the consequences that may result from your refusal. Alternative forms of treatment or help may be available.
I am happy to discuss all of the above-mentioned these rights with you.
LIMITS ON CONFIDENTIALITY
When your information is read by me or other professionals related to your treatment, it is called “use.” If the information is shared with or sent to others outside this office, it is called “disclosure.” Except in some special circumstances, when I use your PHI or disclose it to others, I share only the minimum necessary PHI needed for the purpose. The law gives you rights to know about your PHI, how it is used, and to have a say in how it is disclosed. The law protects the privacy of all communication between a patient and a psychologist. In most situations, I can only release information about our work to others if you sign an Authorization Form that meets clear legal requirements imposed by HIPAA. There are other situations that require your advanced written consent. Your signature on this Agreement provides consent for those activities, as follows:
- I may occasionally find it helpful to consult with other professionals about your case. During a consultation, I make every effort to conceal your identity. Other professionals are also legally bound to keep this information confidential. I will note all consultations in your Clinical Record.
- We, at TEMA Therapy Center, LLC, are a treatment team of mental health professionals who play various roles in serving your mental health needs. I may consult with other members of treatment team regarding varied details of your case. Each treatment team member is bound by the same confidentiality rules.
- Disclosures required by health insurers, or to collect overdue fees are disclosed elsewhere in this Agreement.
- If you present danger to yourself or others, I may be obligated to seek hospitalization for you, and/or to contact family members, and/or anyone else who can help provide protection.
- If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided, or provide for you, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
- If a government agency is requesting the information for health oversight activities, I may be required to provide this to them.
- If you file a complaint or lawsuit against me, I may disclose any relevant information in order to defend myself.
- If I am providing treatment for conditions directly related to a Worker’s Compensation claim, I may have to submit such records, upon appropriate request, to the Chairman of the Worker’s Compensation Board on such forms and at such times as the chairman may require.
- I have to disclose information necessary to enable a patient to apply for or receive benefits when that person is not capable of consenting or is not available to do so.
- I may have to disclose your PHI to a supervising consulting therapist, members of your treatment team, or an attorney consultant. The members of your treatment team may include another psychologist, psychiatrist, mental health counselor, or a social worker who are associates of TEMA Therapy Center, LLC and who are directly involved in providing care and services for you
- I may have to disclose to an officer of the law or prosecuting attorney conducting an investigation of a criminal offense, or attempting to apprehend a fugitive, in which case I may disclose whether a person is present at my office or office building. The police must present a case number and the purpose of the investigation or an outstanding arrest warrant.
- I may have to disclose your PHI to the Office of the Inspector General for the Department of Children and Family Services in cases in which the patient is an alleged perpetrator of abuse or neglect, the subject of an abuse or neglect
- If, in my professional capacity, I receive information from a child or the parents, guardian or other custodian of a child that gives me a reasonable cause to suspect that a child is being abused or neglected, the law requires that I report to the appropriate governmental agency, usually to the statewide central register of child abuse and maltreatment, or to the local child protective services office. Once such a report is filed, I may be required to provide additional information.
- If you communicate an immediate threat of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for you.
Verbal Permission. I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
YOUR RIGHTS REGARDING YOUR PHI: You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing to: Irina Volynsky, Privacy Officer, 440 West Street, Suite 323, Fort Lee, New Jersey 07024:
-Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. Irina Volynsky may charge a reasonable, cost-based fee for copies.
-Right to Amend. If you feel that the PHI Irina Volynsky has about you is incorrect or incomplete, you may ask her to amend the information although Irina Volynsky is not require to agree to the amendment.
-Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that Irina Volynsky makes of your PHI. Irina Volynsky may charge you a reasonable fee if you request more than one accounting in any 12-motnh period.
-Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. Irina Volynsky is not required to agree to your request. Irina Volynsky, however, is required to comply with your request if it relates to a disclosure to your health plan regarding health care items or services for which you have paid the bill in full.
-Right to Request Confidential Communication. You have the right to request that Irina Volynsky communicate with you about medical matters in a certain way or at a certain location.
-Right to a Copy of this Notice. You have a right to a copy of this notice.
If you have a problem with how your PHI has been handled, or if you believe your privacy rights have been violated, please let me know. You have the right to file a complaint with me and with the Secretary of the Federal Department of Health and Human Services. I will not in any way limit your care or take any actions against you if you complain. I am the designated privacy officer for my practice and for the Tema Therapy LLC, and I can be reached by phone at (347) 879-0202.
Irina Volynsky, Ph.D.
AGREEMENT